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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 9  |  Issue : 3  |  Page : 388-391

Erosive Gastroesophageal reflux disease – are we missing pulmonary symptoms?


Department of Gastroenterology, Kottayam Medical College, Thrissur- 680007, Kerala, India

Date of Submission04-Aug-2022
Date of Acceptance01-Sep-2022
Date of Web Publication29-Sep-2022

Correspondence Address:
Dr. Saji Sebastian Kundukulangara
Department of Gastroenterology, Kottayam Medical College, Thrissur- 680007, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mgmj.mgmj_127_22

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  Abstract 

Background: Gastroesophageal reflux disease (GERD) is a common condition that affects about 20- 30% of the adult population, presenting with a broad spectrum of symptoms and varying degrees of severity and frequency. Extra esophageal manifestations like respiratory symptoms are being increasingly recognized. There are only very few studies on the prevalence of pulmonary symptoms in patients with erosive gastroesophageal reflux disease. Aim: The objective of the study was to determine the frequency of pulmonary symptoms in patients with erosive gastroesophageal reflux disease,Materials and Methods: This was a cross-sectional study done on 100 patients diagnosed based on upper gastrointestinal endoscopy findings. Patients were first interviewed about GERD symptoms using the GERD Health-Related Quality of Life questionnaire. Then the respiratory symptoms are assessed. Demographic details are recorded in a proforma. Pulmonary function tests were done on all the patients. Upper GI endoscopic findings are graded according to Los Angeles (LA) grading from A to DResults: The prevalence of pulmonary symptoms was 60%. The most prevalent symptom was a cough, then followed by dyspnoea on exertion, chest pain, wheezing, and snoring. There was a significant association found between LA grading and pulmonary symptoms like wheezing, cough, chest pain, and hoarseness of voice. No significant association was found between GERD duration and pulmonary symptoms. There was a statistically significant association found between LA grading and pulmonary function test. No association was found between quality of life scoring and pulmonary symptoms. Conclusion: There was a high prevalence of pulmonary symptoms in patients with erosive gastroesophageal reflux disease. Erosive GERD can affect pulmonary function according to severity. There was no association between prolonged GERD and pulmonary symptoms.

Keywords: Gastroesophageal reflux disease, health-related quality of life, Los Angeles grading(LA), pulmonary function test


How to cite this article:
Kundukulangara SS. Erosive Gastroesophageal reflux disease – are we missing pulmonary symptoms?. MGM J Med Sci 2022;9:388-91

How to cite this URL:
Kundukulangara SS. Erosive Gastroesophageal reflux disease – are we missing pulmonary symptoms?. MGM J Med Sci [serial online] 2022 [cited 2022 Dec 7];9:388-91. Available from: http://www.mgmjms.com/text.asp?2022/9/3/388/357486




  Introduction Top


Gastroesophageal reflux disease (GERD) is a condition in which regurgitation of gastroduodenal contents occurs in the esophagus from the duodenum or the stomach. Previously thought to be less common in Asians compared to the West and so few studies are available. The most common GERD-related symptoms include heartburn, regurgitation, and difficulty in swallowing. But GERD can be associated with many extraesophageal symptoms with a spectrum ranging from laryngitis, chronic cough, asthma, COPD, recurrent pneumonia, non-cardiac chest pain, and laryngeal cancer.[1]

Gastroesophageal reflux contributes to extraesophageal manifestation either due to aspiration or vagally mediated mechanisms. Reflux of gastro duodenal contents can be classified into two types “high” and “distal”. High esophageal reflux may induce cough either by direct pharyngeal or laryngeal stimulation or by aspiration or by causing a tracheal or bronchial cough response. Cough can be produced by vagally mediated trachea- bronchial reflex due to acid in the distal esophagus. Both esophagus and bronchial tree have a common embryologic origin and neural innervations via the vagus nerve.[2] The most prevalent motility abnormality in patients with GERD – associated respiratory symptoms was ineffective esophageal motility.[3] According to the presence of esophageal mucosal breaks, GERD can be divided into two groups, erosive esophagitis, and non-erosive reflux disease.[4] Erosive esophagitis is described as patients with symptoms of GERD who also have endoscopic evidence of esophageal inflammation. Up to 50% of patients with endoscopically proven esophagitis suffer from symptoms other than heartburn or acid regurgitation.[5] Prevalence of chronic respiratory symptoms in patients with GERD was 18%.[6] As the population-based studies are few, the relation between respiratory symptoms and reflux symptoms in the general population remains unclear.

GERDis a chronic disorder related to the retrograde flow of gastroduodenal contents into the esophagus resulting in a spectrum of symptoms with or without tissue damage.[7] Indian data shows a prevalence of 7.6%.[8] An interview-based study from south India showed a prevalence of 22.2%.[9]

The prevalence of pulmonary symptoms was more common in erosive esophagitis than with non-erosive reflux disease. The relation between respiratory symptoms and reflux symptoms in the population remains unclear. Chronic cough was one of the major pulmonary manifestations of GERD. Patients with persistent coughs with no definite cause may need evaluation for GERD. The objective of the study was to see the frequency of pulmonary symptoms and their association with the severity and duration of erosive GERD. By treating GERD we can reduce lung injury in those patients with pulmonary symptoms.


  Materials and methods Top


Study design

A cross-sectional study was conducted in the Gastroenterology and Pulmonary medicine departments for a period of one year from 2015 September to August 2016.

Patients

All patients diagnosed to have erosive gastroesophageal reflux disease after endoscopy attending the Gastroenterology Department were included. Those with atypical symptoms, malignancy, history of gastrointestinal surgery, chronic lung disease, and those who are pregnant and lactating are excluded from the study. The sample size was taken as 100.

Study procedure

Demographic data and baseline symptoms were recorded in a proforma. All patients underwent detailed history taking, through physical examination and routine investigations. Patients included in the study were first interviewed about gastroesophageal reflux disease symptoms using the GERD health-related quality of life questionnaire (GERD -HRQL). This comprises 16 questions and points from 0 to 5 were used to respond to 10 of these questions as follows; 0- no symptoms,1- symptoms that do not affect daily routine life, and so on progressively up to 5, which indicates constant symptoms that affect the activities of daily life.

Patients with GERD symptoms will undergo upper GI endoscopy and findings are recorded according to the Los Angeles classification from A to D. Those with erosive esophagitis were included in the study. They are then assessed for respiratory symptoms such as chronic cough, dyspnoea on exertion, wheeze, chest pain, snoring, and hoarseness of voice. Chronic cough was defined as a recurrent and persistent non-obstructive cough for 2 months or longer. Dyspnoea was graded by the modified medical research council (MMRC) dyspnoea scale.

Data analysis

Data were collected, coded, and entered into Microsoft excel 2007. The whole data was rechecked and analyzed using statistical software SPPS version 16. Demographic variables of GERD were expressed in rates and percentages. The association between GERD and pulmonary symptoms was checked with Pearson’s chi-square test. If the expected count of any cell was less than 5, Fischer’s exact test was used.


  Results Top


The mean age of the patients was 50.01 ± 14.42 years. The majority were in the age group of 36-45yrs. Males predominated the study (68%). Most of them (72%) had a BMI between 18.5 TO 24.9. Only 19% of them were regularly taking alcohol.17% of them are current smokers and 19% were ex-smokers. Symptoms of GERD were there for 6months to one year in the majority of the patients (41%). Heartburn was the most common symptom (52%) experienced by the patients, followed by regurgitation. GERD-related HRQOL was <30 in the majority of the patients (82%). On endoscopy majority of them had grade A (54%) esophagitis and 38% had grade B esophagitis in the Los Angeles classification.

Out of the study subjects, 60% had pulmonary symptoms. The majority were males (60%) and had a BMI between 18.5 to 24.9. (71.7%) Pulmonary symptoms were present in 36(60%) of those who never smoked,10(16.7%) of ex-smokers, and in 14(23.3%) of current smokers. GERD- Health-Related Quality of Life (HRQOL) was less than 30 in 58.5% (48) of patients.

The common pulmonary symptoms were cough (38%), dyspnoea on exertion (34%), chest pain (23%), wheeze (14%), snoring (12%), and hoarseness of voice in 4%. Among the patients with pulmonary symptoms, the pulmonary function test showed a restrictive pattern in 14 patients, obstructed pattern in 11 patients, and a mixed pattern in 4 patients. 31 patients showed a normal PFT. Out of the 14 patients having wheeze, those with grade D (2 patients) esophagitis on the Los Angeles score, all had a wheeze. Fischer’s exact value was 10.44 and their p-value of 0.01.

Out of the 38 patients with cough 26 had grade A esophagitis. Only 2 had grade D esophagitis. Fischer’s exact value was 13.44 and the p-value was 0.004. Those with hoarseness of voice were 4 patients. Fischer’s exact value was 8.84 and their p-value of 0.03. 23 patients had chest pain and the majority (18) had grade A or B esophagitis – with Fischer’s exact value of 9.27 and p-value of 0.02. Snoring was seen in 12 patients and the majority (7) had grade B esophagitis- Fischers exact value was 6.26 and a p-value of 0.09. Dyspnoea was seen in 34patients and the majority had grade A or B esophagitis (29%)- Fischer’s exact value was 6.03 and p-value of 0.1.

No statistically significant association was found between GERD duration and pulmonary symptoms. In this study, the pulmonary function test was normal in 68% of patients. The restrictive pattern was seen in 15%, the obstructive pattern in 13%, and the mixed pattern in 4% of patients. Even though there was only a small number of patients with severe grades of GERD, there was a significant association found between LA grading and pulmonary function test [Table 1]. In higher grades of erosive reflux disease, all patients had abnormal pulmonary function tests. Among the 14 patients with wheeze, 9(64.3%) patients had obstruction on PFT with a statistically significant association (P < 0.001)
Table 1: Showing LA Grading and pulmonary function test

Click here to view



  Discussion Top


Gastroesophageal reflux disease is a common condition affecting the adult population with prevalence ranging from 7–20%.[10],[11] GERD can present with a wide range of extraesophageal symptoms like chronic cough, wheeze, chest pain, and breathlessness. Pulmonary symptoms were common in patients with erosive gastroesophageal reflux disease.[12] Erosive GERD was defined as the presence of evident mucosal injury at endoscopy. All the patients included in the study had proven GERD by upper gastrointestinal endoscopy.

This study demonstrated that pulmonary symptoms were more common in patients with erosive gastroesophageal reflux disease with a prevalence of 60%. This was comparable to the study by Maher and Darwish where the prevalence of respiratory symptoms in erosive reflux disease was 60%.[13] Cough was the most predominant symptom followed by dyspnoea on exertion, chest pain, wheezing snoring, and hoarseness of voice. Erosive GERD was affecting pulmonary function according to its severity. No significant association was found between prolonged GERD and pulmonary symptoms. Severe GERD was found to be a significant risk factor for wheezing, chest pain, and hoarseness of voice. Pulmonary function tests were normal in the majority of the patients. But there was a statistically significant association between higher grades of erosive esophagitis and abnormal pulmonary function tests. Among patients with pulmonary symptoms majority (23.3%) showed restrictive patterns and obstructive patterns in 18.3%, In patients with wheeze majority had an obstructive pattern, which was statistically significant.

There was a high prevalence of pulmonary symptoms in patients with erosive gastroesophageal reflux disease, in which cough was the most predominant symptom, followed by dyspnoea on exertion, chest pain, wheezing, snoring, and hoarseness of voice. Similar results were also noted in the study by Yang won Min et al.[12] Erosive esophagitis was also affecting pulmonary function according to the severity of LA grading.[13] No significant association was there between prolonged GERD and pulmonary symptoms. Severe grades of GERD were found to be a significant risk factor for wheeze, chest pain, and hoarseness of voice

In summary those with severe GERD, we should enquire about the pulmonary symptoms. For those with chronic pulmonary symptoms, it will be better to rule out GERD by every means before embarking on higher investigations.


  Conclusion Top


Erosive GERD can affect pulmonary function according to the severity of the erosions (Los Angeles grading). Those with higher grades of reflux esophagitis can have abnormal pulmonary function tests. Duration of symptoms of GERD was not associated with pulmonary symptoms.

Limitations of the study

We have not included all patients with GERD in the study, only those with endoscopy-proven erosive GERD patients were included. Studies with pH monitoring and manometry to document reflux are warranted for better documentation of reflux.

Ethical consideration

The Institutional Ethics Committee(IEC)/Institutional Review Board (IRB) of Government Medical College, Thrissur, Kerala, India, has approved the proposal for undertaking the research study on “Frequency of pulmonary symptoms in patients with erosive gastroesophageal, reflux disease” vide their letter dated 10 December 2014.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Dirou S, Germaud P, Bruley des Varannes S, Magnan A, Blanc FX [Gastro-esophageal reflux and chronic respiratory diseases]. Rev Mal Respir 2015;32:1034-46.  Back to cited text no. 1
    
2.
Andersen LI, Schmidt A, Bundgaard A Pulmonary function and acid application in the esophagus. Chest 1986;90:358-63.  Back to cited text no. 2
    
3.
Fouad YM, Katz PO, Hatlebakk JG, Castell DO Ineffective esophageal motility: The most common motility abnormality in patients with GERD-associated respiratory symptoms. Am J Gastroenterol 1999;94:1464-7.  Back to cited text no. 3
    
4.
Ha NR, Lee HL, Lee OY, Yoon BC, Choi HS, Hahm JS, et al. Differences in clinical characteristics between patients with non-erosive reflux disease and erosive esophagitis in korea. J Korean Med Sci 2010;25:1318-22.  Back to cited text no. 4
    
5.
Jaspersen D, Nocon M, Labenz J, Leodolter A, Richter K, Stolte M, et al. Clinical course of laryngo-respiratory symptoms in gastro-oesophageal reflux disease during routine care–a 5-year follow-up. Aliment Pharmacol Ther 2009;29:1172-8.  Back to cited text no. 5
    
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Róka R, Rosztóczy A, Izbéki F, Taybani Z, Kiss I, Lonovics J, et al. Prevalence of respiratory symptoms and diseases associated with gastroesophageal reflux disease. Digestion 2005;71:92-6.  Back to cited text no. 6
    
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Moraes-Filho JP, Chinzon D, Eisig JN, Hashimoto CL, Zaterka S Prevalence of heartburn and gastroesophageal reflux disease in the urban brazilian population. Arq Gastroenterol 2005;42:122-7.  Back to cited text no. 7
    
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Bhatia SJ, Reddy DN, Ghoshal UC, Jayanthi V, Abraham P, Choudhuri G, et al. Epidemiology and symptom profile of gastroesophageal reflux in the indian population: Report of the indian society of gastroenterology task force. Indian J Gastroenterol 2011;30:118-27.  Back to cited text no. 8
    
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Wang HY, Leena KB, Plymoth A, Hergens MP, Yin L, Shenoy KT, et al. Prevalence of gastro-esophageal reflux disease and its risk factors in a community-based population in southern india. BMC Gastroenterol 2016;16:36.  Back to cited text no. 9
    
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Sharma PK, Ahuja V, Madan K, Gupta S, Raizada A, Sharma MP Prevalence, severity, and risk factors of symptomatic gastroesophageal reflux disease among employees of a large hospital in northern india. Indian J Gastroenterol 2011;30:128-34.  Back to cited text no. 10
    
11.
Kumar S, Sharma S, Norboo T, Dolma D, Norboo A, Stobdan T, et al. Population based study to assess prevalence and risk factors of gastroesophageal reflux disease in a high altitude area. Indian J Gastroenterol 2011;30:135-43.  Back to cited text no. 11
    
12.
Min YW, Lim SW, Lee JH, Lee HL, Lee OY, Park JM, et al. Prevalence of extraesophageal symptoms in patients with gastroesophageal reflux disease: A multicenter questionnaire-based study in korea. J Neurogastroenterol Motil 2014;20:87-93.  Back to cited text no. 12
    
13.
Maher MM, Darwish AA Study of respiratory disorders in endoscopically negative and positive gastroesophageal reflux disease. Saudi J Gastroenterol 2010;16:84-9.  Back to cited text no. 13
    



 
 
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